Nocturnal Lagophthalmos: An Overview and Classification

Nocturnal lagophthalmos is the inability to close the eyelids during sleep. Lagophthalmos is associated with exposure keratopathy, poor sleep, and persistent exposure-related symptoms. There are a variety of causes of lagophthalmos, grouped as proptosis/eye exposure etiologies and palpebral insufficiency etiologies. Although obvious lagophthalmos is usually detected, it is sometimes difficult to recognize obscure lagophthalmos, due either to eyelash obstruction or overhang of the upper lid anterior and inferior to the most superior portion of the lower lid in a closed position. We present a novel classification system and illustrations of obvious and obscure lagophthalmos. A diagnosis can usually be made with a focused history and slit lamp examination. Treatment is multipronged and may include minor procedures or ocular surgery to correct the lid malposition; natural, topical or oral agents; and punctal plugs to manage ocular surface effects. Correct and timely diagnosis allows greater opportunity for relief of patient suffering and prevention of severe ocular surface pathology, as well as educated planning for future ocular surgical procedures.

Lower Eyelid Laxity in Functional Acquired Epiphora: Evaluation With Quantitative Scintigraphy

PURPOSE

The examination of lacrimal drainage is often based on qualitative criteria. This study uses quantitative scintigraphy to evaluate "functional" epiphora.

METHODS

Thirty-two patients with functional epiphora (no morphologic abnormalities of the conjunctiva and eyelids, a patent nasolacrimal duct on irrigation, and no anatomical stenosis on dacryocystography) were studied (study group, SG). Twenty-two individuals without epiphora were also examined (control group, CG). Fifty microliters of Technetium-99m was instilled into the conjunctival cul-de-sac. Time-activity curves were then constructed, and conjunctival lacrimal clearance (CLC) at 2.5, 5, 7.5, and 10 minutes was calculated. Differences in CLC between the SG and the CG and correlations between CLC and horizontal and median tendon laxity and eyelid length in the SG were examined.

RESULTS

The SG had significantly reduced CLC at 2.5 and 5 minutes, compared with the CG (p = 0.01 and p = 0.04, respectively), whereas respective differences at 7.5 and 10 minutes were not statistically significant. In the SG, CLC at 2.5 and 5 minutes was significantly correlated with horizontal and median tendon laxity. The respective correlation with eyelid length was not statistically significant. Furthermore, in the SG, CLC at 2.5 and 5 minutes was significantly correlated with patient age (p = 0.03 and p = 0.04, respectively). Differences in CLC between men and women were not statistically significant at all intervals.

CONCLUSIONS

The correlation between eyelid laxity and CLC supports the role of the eyelid "pump" in lacrimal drainage. CLC at 2.5 and 5 minutes may be used to decide treatment methods for functional epiphora.

Bell's palsy-induced blepharospasm relieved by passive eyelid closure and responsive to apomorphine

OBJECTIVE

We describe the case of a woman with Bell's Palsy-induced blepharospasm (BPIB) of the right eye that appeared simultaneously with a complete left facial nerve palsy. The involuntary spasm was relieved by passive lowering of the upper eyelid on the paretic side.

METHODS

The recovery curve of the blink reflex was evaluated on the non-paretic side in baseline conditions, after subcutaneous apomorphine and placebo administration and 8 months later, at recovery from the palsy.

RESULTS

We found increased recovery of the test-R2 responses at short interstimulus intervals at baseline, which was normalised by apomorphine but not by placebo. At recovery the blink reflex R2 recovery curve returned to normal.

CONCLUSIONS

This report demonstrates for the first time a response of BPIB to a dopamine agonist.

SIGNIFICANCE

Our findings are in agreement with an animal model of blepharospasm that suggests a combined role of weakness of the orbicularis oculi muscle and a dysfunction of the dopaminergic system in the pathogenesis of this disorder.

Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material

PURPOSE

To compare two sling designs (single loop or double pentagon) and a variety of suture material that was used in frontalis suspension surgery for correction of upper eyelid ptosis.

DESIGN

Retrospective, nonrandomized, comparative interventional case series.

METHODS

Medical record review of 99 patients (164 surgeries) who underwent frontalis suspension surgery for upper eyelid ptosis was conducted at the Jules Stein Eye Institute in 1996 to 2002. Functional and cosmetic success, margin reflex distance (MRD) and lagophthalmos were evaluated.

RESULTS

MRD increased an average of 1.1 mm after the operation (P < .001). Ptosis recurrence was noticed in 42 cases (26%); polytetrafluoroethylene achieved the lowest recurrence rate (15%), although not statistically significant. No difference in functional success, ptosis recurrence, or change in MRD was noticed between single loop and double pentagon design. A better cosmetic outcome was noted in cases in which nylon suture was used. Complications included four cases (2.4%) of over-correction, three cases (1.8%) of suture infection (all in polytetrafluoroethylene), two cases of pyogenic granuloma (1.2%), and two cases (1.2%) of suture exposure.

CONCLUSION

Frontalis suspension for upper eyelid ptosis resulted in 26% ptosis recurrence after a mean of 12 months from first surgery. Polytetrafluoroethylene showed the lowest incidence of ptosis recurrence. No statistically significant difference was found between different suture materials or loop shape that was used in the surgical technique. A better cosmetic outcome, as graded by different observers, was noted in cases in which a nylon sling was used.

Disruption of Bardet-Biedl syndrome ciliary proteins perturbs planar cell polarity in vertebrates

The evolutionarily conserved planar cell polarity (PCP) pathway (or noncanonical Wnt pathway) drives several important cellular processes, including epithelial cell polarization, cell migration and mitotic spindle orientation. In vertebrates, PCP genes have a vital role in polarized convergent extension movements during gastrulation and neurulation. Here we show that mice with mutations in genes involved in Bardet-Biedl syndrome (BBS), a disorder associated with ciliary dysfunction, share phenotypes with PCP mutants including open eyelids, neural tube defects and disrupted cochlear stereociliary bundles. Furthermore, we identify genetic interactions between BBS genes and a PCP gene in both mouse (Ltap, also called Vangl2) and zebrafish (vangl2). In zebrafish, the augmented phenotype results from enhanced defective convergent extension movements. We also show that Vangl2 localizes to the basal body and axoneme of ciliated cells, a pattern reminiscent of that of the BBS proteins. These data suggest that cilia are intrinsically involved in PCP processes.

Treatment of tear trough deformity and lower lid bowing with injectable hyaluronic acid

Tear trough deformity of the lower eyelid is one of the most difficult depressions to correct surgically. The thin skin of the trough, the overhanging abundant lower lid fat, the underlying cheek mound, and the tethering effect of the orbitomalar ligament create a surgical challenge. Until now, noninvasive methods used to treat this depression have been problematic, yielding a poor benefit-to-risk ratio in most hands. Even surgery does not completely manage this depression. The most common surgical techniques for lower eyelid rejuvenation do not even address it. Since December of 2003, 24 patients have had their tear troughs treated with injectable hyaluronic acid. For 23 patients, Restylane was injected superficially to elevate the surface from the orbitomalar ligament and add volume to the trough. Only two patients were dissatisfied with their results.

Epiphora with eyelid laxity

PURPOSE

To determine the efficacy of lower lid tightening procedures in the management of epiphora due to eyelid laxity.

METHODS

Retrospective audit of 75 eyes in 49 patients with lid laxity and no nasolacrimal obstruction, who underwent lower lid tightening procedures for epiphora between November 2001 and June 2003. Relief from epiphora was assessed at the last clinic visit following surgery and by telephone interview in March-April 2004.

RESULTS

Complete relief from epiphora persisted in 47 eyes (62.6%) as compared with 53 eyes (70.6%) at one month, and partial relief persisted in a further six eyes (8%). Eleven eyes (14.6%) with complete and five eyes (6.7%) with partial relief at discharge had recurrence of symptoms at follow-up. Mean follow-up time was 16.9 months. There was no statistically significant difference in relief between those with lateral and medial epiphora.

CONCLUSIONS

Lid tightening surgery is useful in alleviating epiphora in a significant number of patients with lid laxity but the effect does not always last.

Lidschlagaktivität während der Bildschirmarbeit

New findings based on a noninvasive, automated long-term measurement method revealed interindividual differences in lid movement behavior, existence of blinking patterns, and the dominance of cognitive influence in the regulation of blinking frequency during increased concentration and especially visual attention. The development of an individual blinking animation promises long-lasting increase and harmonization of lid movements during visual display work. Maintenance of the integrity of the ocular surface by preventing surface evaporation and providing sufficient precorneal environment eradicates important pathogenic factors of ocular discomfort. An animation program for stimulation of blinking has been developed. First results showed that an increase in blinking rate initiated by the computer itself is feasible in principle during work at a visual display terminal. Further improvement of this new approach is promising.

Thalamocortical theta coherence in neurological patients at rest and during a working memory task

We simultaneously recorded the local field potential (LFP) in the thalamus and the electroencephalogram (EEG) on the scalp of 5 patients suffering from neurogenic pain, epilepsy and movement disorders. In an earlier study [], we have investigated the slowing of EEG and the high thalamocortical coherence in the framework of thalamocortical dysrhythmia, the common underlying pathophysiology. The current study focuses on the effects of different cognitive conditions. When patients rested with eyes closed, a theta peak dominated the EEG spectra. The peak height was reduced upon opening the eyes, reminiscent of the classical alpha blocking. This peak reduction also appeared in the thalamic LFP recording. When patients activated their working memory by counting backwards, the theta peak increased in scalp EEG or in the LFP recorded in thalamic nuclei VA/VL. The coherence estimates between EEG and LFP ranged between 21% and 76% for different patients and cognitive conditions (mean: 50%). The involvement of both cortex and thalamus in working memory and the high thalamocortical coherence underline, in addition to cortico-cortical interactions, the importance of thalamocortical modules in the generation of higher cognitive functions.

Open Sky M??ller Muscle-Conjunctival Resection in Phenylephrine Test-Negative Blepharoptosis Patients

PURPOSE

To assess the efficacy of Müller muscle-conjunctival resection in patients in whom the phenylephrine test was negative.

METHODS

A non-randomized, prospective clinical trial was conducted on 20 eyelids of 15 consecutive patients with blepharoptosis who showed no change in the upper eyelid margin-reflex distance (MRD1) following instillation of topical phenylephrine. The technique used was open sky Müller muscle-conjunctival resection.

RESULTS

The mean MRD1 increased by 3.3 mm. No patient required augmentation of the procedure, and all patients had excellent appearance of their skin crease and eyelid contour. No complications arose from the procedure, including no incidence of dry eye symptoms or signs.

CONCLUSIONS

Müller muscle-conjunctival resection may offer a safe and effective means of treating blepharoptosis despite a negative phenylephrine test.

Making GCS as Easy as 1, 2, 3, 4, 5, 6

The Glasgow Coma Scale (GCS) is an easy to use tool for assessing neurological function and brain injury in comatose patients particularly in acute stages of traumatic injury or illness. Due to the simplicity of the scale, however, proper training is often overlooked limiting its usefulness. This manuscript describes the basic components of the GCS and the proper scoring method to elicit accurate evaluations.

Efficacy and safety of a new Botulinum Toxin Type A free of complexing proteins in the treatment of blepharospasm

NT 201 is a new development of Botulinum Toxin Type A free of complexing proteins. In this double-blind Phase III trial, we compared the efficacy and safety of NT 201 and BOTOX in patients suffering from blepharospasm. Of 304 enrolled patients, 300 patients received study medication (intent-to-treat population), and 256 patients completed the study as planned (per-protocol population). At baseline, patients received a single injection of NT 201 or BOTOX (<or=35 units per eye). No significant differences were found between NT 201 and BOTOX for all efficacy and safety variables three weeks after injection. Both the NT 201 and the BOTOX group showed a decrease in the Jankovic Rating Scale (JRS) sum score signifying an improvement in the symptoms of blepharospasm during this time period. These data show that NT 201* is an effective and safe treatment for patients suffering from blepharospasm.

Combined Hard Palate Spacer Graft, Midface Suspension, and Lateral Canthoplasty for Lower Eyelid Retraction: A Tripartite Approach

BACKGROUND

Eyelid retraction is an unfortunate consequence of cosmetic surgery, trauma, and disease states. It is frequently symptomatic and may be associated with dry eye syndrome and corneal compromise. The pathophysiology of lower eyelid retraction usually involves some degree of lateral canthal tendon laxity, middle lamella scarring, and malar descent. The authors describe for the first time a series of patients whose lid retraction was treated with a tripartite procedure that addresses all three pathophysiologic components simultaneously and rehabilitates the patients cosmetically and functionally.

METHODS

The authors retrospectively reviewed the records of 17 patients (24 eyelids) operated on between 1999 and 2003 by one senior surgeon. The age of the patients ranged from 26 to 77 years (mean, 50.3 years), and all presented with significant scleral show (average, 2.0 mm) and symptomatic corneal exposure from a variety of causes. Preoperatively, all patients were noted to have a combination of lower eyelid laxity, middle lamellar contracture, and malar descent. Preoperative and postoperative examinations included Shirmer's test, a measurement of scleral show, and a slit-lamp examination. Mean follow-up time was 13 months. All patients underwent a triad of hard palate spacer grafting, lateral canthal suspension, and midface elevation.

RESULTS

All 17 patients (representing 24 retracted eyelids) had complete resolution of scleral show (2.5-mm average correction) and were uniformly satisfied with their cosmetic and functional outcome at last follow-up. Preoperative dry eye symptoms resolved in all patients in the series. There were no major complications and only two minor complications (corneal irritation from graft sutures in one patient and an oronasal palatal fistula in another), both of which resolved in the early follow-up period.

CONCLUSIONS

The combination of hard palate spacer grafting, lateral canthoplasty, and midface suspension is an effective, aesthetic, and functional treatment for moderate to severe lower eyelid retraction resulting from multiple causes. This tripartite procedure is associated with predictable results, a low morbidity rate, and high patient satisfaction.

Near work induced wavefront aberrations in myopia

We undertook a detailed analysis of the wavefront aberrations of the eyes of 20 young progressing myopes (mean age=22 years; mean spherical equivalent=-3.84 D, range -1.00 to -7.5 D) and twenty young age matched emmetropes (mean age=23 years; mean spherical equivalent=-0.00 D, range +0.25 to -0.25 D). A wavefront sensor was used to measure the ocular wavefront and a videokeratoscope was used to measure corneal topography. The corneal wavefront was subsequently calculated and the difference between the corneal and ocular wavefront was derived to give the internal wavefront component of the eye. Ocular and corneal wavefronts were measured before and after a 2-h reading task. At the baseline measurements, the myopes showed greater levels of some high order ocular wavefronts than the emmetropes. These differences between the groups became larger following 2 h of reading. Ocular higher order wavefront RMS was (baseline RMS: myopes=0.21 microm, emmetropes=0.16 microm, difference p=0.05 and after 2 h reading was RMS: myopes=0.27 microm, emmetropes=0.17 microm, difference p=0.02). The differences between the groups are primarily due to changes in the corneal wavefront associated with a narrower lid aperture during reading for the myopes. These differences are enhanced by longer periods spent reading, larger pupils and consequently low light levels. We suggest lid induced corneal changes caused by reading in downgaze provides a theoretical framework that could explain the known features of myopia development. The inherited characteristics of facial and lid anatomy would provide a mechanism for a genetic component in the genesis of myopia.

Postoperative Chemosis After Cosmetic Eyelid Surgery

Persistent conjunctival chemosis in patients who have undergone cosmetic eyelid surgery is an uncommon but aesthetically undesirable and potentially debilitating postoperative complication. We attempted to determine if a regional conjunctivoplasty can effectively reduce signs and symptoms of chronic postoperative chemosis in these patients. Three patients with iatrogenic chemosis resistant to conservative management (ie, lubrication, pressure patching, and steroid drops) and persisting for more than 6 months after the initial surgery were included. A limbal peritomy followed by subconjunctival and sub-Tenon's fascia dissection was performed in regions of clinically detectable chemosis. Patients were followed postoperatively for 3 to 9 months to assess clinical response. All patients demonstrated significant objective improvement in clinically observable chemosis as well as symptoms related to ocular surface dryness.

Effect of darkness on upper eyelid position

PURPOSE

To determine the magnitude of upper eyelid retraction induced by sudden darkness in normal subjects and in patients with Graves upper eyelid retraction before and after treatment with guanethidine drops.

METHODS

The study comprised 211 control subjects (n=211 eyes) and 45 patients (n=78 eyes) with Graves upper eyelid retraction. The control subjects were divided in four age groups: 0 to 1 year, 2 to 9 years, 0 to 18 years, and 19 to 61 years. Twenty-one patients with Graves upper eyelid retraction (n=39 eyes) used guanethidine drops for 15 days. Palpebral fissure images of subjects were acquired in photopic conditions and in darkness. For both images, the distance between the mid-pupil and upper eyelid margin was measured.

RESULTS

Darkness induced upper eyelid retraction in all subjects. The increment in the mid-pupil eyelid distance was greater in children. There was no significant difference between the magnitude of eyelid elevation of Graves patients and normal adults. Guanethidine drops did not abolish the eyelid reflex in Graves patients.

CONCLUSIONS

Darkness provokes upper eyelid retraction in control subjects and in patients with Graves upper eyelid retraction. This effect decreases with age and does not result from sympathetic stimulation of the Muller muscle.

Ultrasonic visualization of the effect of blinking on the lacrimal pump mechanism

BACKGROUND

The role of the lacrimal sac (LS) and the medial canthal tendon in the lacrimal pump mechanism is controversial. This study used ultrasonic visualization to analyze this phenomenon.

METHODS

Movements of the LS and the medial canthal tendon during blinking were visualized with sonography. In addition, the maximal profile area of the LS was measured before and after blinking using 15-MHz sonography in 14 individuals with a normal lacrimal drainage system and in six patients with lacrimal duct obstruction.

RESULTS

The upper part of the LS could be located as an echolucent structure between the lacrimal bone and the medial canthal tendon. The medial canthal tendon appeared to compress the LS during lid closure and release the LS during lid opening. The measured profile area of the visible normal LS at the compression time decreased by 50%. The dilated LS of patients with obstruction could also be compressed by the orbital muscle on blinking, but the maximum area decrease was only 15.5%.

CONCLUSION

The findings imply that the lacrimal part of the orbicularis muscle contracts during blinking, with the medial canthal tendon compressing the LS in a cranial direction. Completion of lid closure then compresses both canaliculi and LS, forcing the intrasacral fluid through the drainage system. The expansion of the LS during the opening phase of the blink causes suction, and after opening of the punctal areas the canaliculi and LS vacuum breaks to reload with tear fluid. These findings demonstrate the importance of the orbicularis muscle and the medial canthal tendon for the lacrimal pump mechanism during blinking.

Eyelid aging: the historical evolution of its management

The evolution of blepharoplasties is reviewed. By better understanding the mechanism of herniated lower eye lid fat pads, one can understand the interrelated enophthalmia, tear trough deformities, and sunken upper lid. The authors use a technique of relocating the herniated fat pad that reverses this process. All of this is described in detail.